Wednesday, February 21, 2018
According to CNN, Aetna’s former medical director, Ken Iinuma, admitted in a deposition that “he never looked at patients' records when deciding whether to approve or deny care” surprises me for reasons that I suspect are different from the reasons the public seems shocked (California has reportedly opened an investigation). The public may shake its collective head in disbelief that life and death decisions regarding insurance coverage (or the lack thereof) could be made in a paper-review. Those of us who have been involved in medicolegal practice of one kind or another realize this is probably the rule rather than the exception. Because of the sheer volume of insurance-coverage determinations made within large organizations, it is not surprising that individual medical records are not made by top decision makers. Aetna will no doubt argue to California that its internal administrative process ferrets out bad decisions (or at least highlights questionable front-line decisions) long before the file makes its way to a top decision maker. This is, after all, the way that legal organizations like workers’ compensation commissions reach decisions. Deep scrutiny of all files would be expensive and time consuming. True, one might hope that a doctor (with due respect to you nurses) would take the time to at least peek at underlying records when denial of treatment will likely lead to death.
But that is not what surprises me. I am surprised by the nakedness of the admission of the doctor (perhaps unsurprisingly no longer an employee of Aetna), though I would have to read the entire deposition transcript to learn if things were really as stark as they seem. Sometimes the most damning admissions emerge because an inside player has lost the ability to discern when things look bad to the outside world. This method of paper denial had apparently become so routine to the doctor that he, perhaps momentarily in a moment of fatigue, failed to appreciate the perception of decisions under such processes as mere rubber stamps.
At another level, the public might be shocked because it believes a doctor is a doctor first and an employee of an organization only secondarily. Surely, the doctor would not sacrifice his professional ethics at the altar of crass employment.
I think that the potential for relinquishment of professional judgment undergirds much of what workers’ compensation has become. Were the late 19th-century architects of workers’ compensation naïve in believing that the ADR-system they apparently thought workers’ compensation would become could operate without lawyers? My profession takes a lot of heat for its perceived unfettered embrace of adversarialism. But as all of you in “the business” know, acquisition of medical evidence can be a de facto arms race. There is plenty of blame to go around for the present state of affairs. Perhaps the public will now have to wake up to a reality that many of us have long known.
Michael C. Duff